1. Credentialing Experience Health Plan Perspective NYSAMSS Conference – 5/9/2019

2. Challenges, Issues or Obstacles with Practitioner Application
Eligibility:
Network closed to provider’s specialty
Credentialing/contracting for specialty delegated to another organization
Network does not operate in the region where provider renders service
Provider does not have privileges in network facility
Physician applicant without successful completion of ACGME/AOA accredited residency training in the practicing specialty
Applicant has current license sanction/encumbrance
Insufficient professional liability coverage
Applicant does not have a valid Medicaid ID # and is not listed on State’s pending list
Current Medicaid/Medicare sanction/exclusion against provider and/or provider’s practice
Service location/office not operational at time of application/site assessment
Provider did not authorize plan to access CAQH application
Expired or incomplete CAQH application and/or supporting documents
Discrepancies between application information and verification results (e.g. application states provider is board certified, but verification shows provider’s certification expired.)
Unexplained gaps in work history.
Delayed/lack of response from provider

3. Challenges, Issues or Obstacles with Application
Group:
Some of the providers in the group are not interested in joining the plan
Not all providers in the group meet plan’s eligibility requirements
Some of the providers in the group were denied by the Credentialing Committee
Facility:
Network is closed to service
Credentialing/contracting for specialty delegated to another organization
Network does not operate in the region where provider renders service
Facility does not meet eligibility requirements (e.g. social adult day care center without documented evidence that facility filed annual NYS Social Day Care Certification)
Insufficient commercial general professional liability coverage
Facility (in the Medicaid must enroll category) does not have a valid Medicaid ID # and is not listed on State’s pending list
Facility has current Medicaid/Medicare sanction/exclusion
Service location/office not operational at time of application/site assessment
Incomplete application and/or supporting documents (e.g. Article 28 facility without evidence of compliance with annual OMIG SSL/DRA certification)
Discrepancies between application information and verification results
Delayed/lack of response from provider

4. Positives in the Credentialing Experience
Knowledgeable
Providers (regardless of type – practitioner, group or facility) and credentialing agents knows regulatory and plan requirements.
Responsiveness
Providers (regardless of type – practitioner, group or facility) and credentialing agents responds timely to requests for additional information and provides full information where applicable (e.g. full explanation of provider’s involvement in care of patient in settled cases.)
Data Accuracy
Accurate information ensures access to care, reimbursement for services rendered, accurate provider directory and reduces/eliminates risk to plan.

5. Accurate Credentialing Information
Pointers:
Provider’s Name – should match the information on New York State file as reflected in verification responses. So, if the provider has middle initial on the State file, then the name on provider application or name submitted by the facility must include the middle name.
When provider name differs from information on the State file our Core System Department cannot submit the providers information to the State as part of our provider data network information. So, the record is flagged for correction prior to PNDS submission.
Specialty – provider’s specialty information in credentialing system must match the information in the provider directory and the information in the claims system. So provider, group practice or facility must accurately record/submit provider’s specialty information. When dual specialty provider renders service in only one specialty the provider, group or facility should provide the name of the practicing specialty only. Is the cardiologist rendering both internal medicine and cardiology services? Is the OB/GYN specialist treating pregnant moms and delivering babies, or does s/he provide only gynecology services?

6. Pointers Continued Provider Directory:
Regulatory agencies, such as CMS, mandate accurate directory and allows up to 30 calendar days for plans to make update provider information/directory.
Required Directory Information:
Is provider accepting new members?
Provider limitations (inpatient only, homeless only etc.) must be identified?
Directories may only list providers who enrollees can go to for appointments?
On-call and substitute providers who don’t regularly provide covered service should not be listed in directory. So, these providers should be sent with limitation (inpatient or covering only).
Dual specialty provider – information for providers credentialed for more than one specialty must be clear to guard against enrollee confusion. For example, a cardiologist provides inpatient ward attending coverage 3 times a year AND sees patient in the monthly cardiology clinic – the delegated spreadsheet should show two rows for this provider. One will list the provider as a specialist (with the days and hours that he accepts members in the Cardiology clinic. The second row will list the provider as a covering Internal Medicine PCP with closed panel, limitation “inpatient only.”
Days and hours information required for Active providers who are published in the directory. When the days and hours are left blank, we cannot enter provider. This delays the provider load.

7. Pointers continued
Non-physician providers (for example nurse practitioner, PA, etc.) – if non-physician providers are listed, then enrollee must be able to call and make an appointment with that provider, and directory must clearly note that the provider is a non-physician provider.
Non-physician providers listed in the directory must have a current credentialing file. So, non- physician providers that are not credentialed by Medical staff Credentialing Committee process cannot be published in the directory.
Regulatory Changes – As of 4/1/2017, timeframe for completing credentialing process is 60 days. So, providers must comply with plan’s request for information or applications are discontinued.

8. Regulatory Changes continued
MMIS – effective 1/1/2018 all participating providers must be enrolled in New York State Medicaid program.
Participating providers without valid Medicaid ID must apply for enrollment by 12/1/2017
As of 1/1/2018:
New providers must have a valid Medicaid ID.
Participating providers without valid Medicaid ID will be removed from the network.
Providers who only want to service patients can enroll as a non-billing, Ordering/Prescribing/Referring/Attending (OPRA) provider.
Practitioners can verify if they are enrolled by using the enrolled practitioners search function on
Providers need to go to and navigate to their provider type to print instructions and enrollment form.